The Richard E. Weimer Stroke and Caregiver Assistance Fund

The Richard E. Weimer Stroke and Caregiver Assistance Fund
MonthDayYear
Full Name

First NameLast Name
Date of Birth

MonthDayYear
E-mail
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Phone Number

Area CodePhone Number
Brief Statement of Need
Current Assistance Being Received

MedicareMedicaidSNAPDD BenefitsSpecial Needs TrustSSISSDIOtherOther
Letters of Support (pdf)

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Applying as Member of

Kalakaua Ohana ClubFirst Presbyterian Church of Honolulu
Assistance Requested

MealsTransportationEquipmentClothingPhysical TherapyMedical Need (not covered by insurance)Caregiving CostsSpiritual CounselingEmotional / Psychological CounselingOtherOther
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